EXECUTIVE SUMMARY

2017 PPS-PIDSP CLINICAL PRACTICE GUIDELINES ON DENGUE

Current World Health Organization estimates show that 50 to 100 million new dengue
infections occur yearly. In affected regions such as Asia and Latin America, severe
dengue is a leading cause of hospitalization and mortality particularly in children. While
there is no specific treatment for dengue, prompt recognition and timely intervention
affects prognosis.

This current evidence-based guideline updates the recommendations contained in the

PPS 2008 Practice Guidelines on DF/DHF answering relevant questions in the care of a
child with dengue illness. The intended users of this document include primary care
physicians, family medicine physicians, pediatricians, and other healthcare workers
involved in the diagnosis and management of dengue in children.

The eight priority questions identified and corresponding recommendations were

developed by a 16-member group of experts composed of an Oversight Committee, a
Guideline Writing Panel and a Technical Review Committee. Quality and strength of
evidence was rated using the GRADE methodology. Draft recommendations presented
in the table below were finalized after these were presented to and voted on by the
members of the Stakeholders Panel.

No. Recommendation Strength of Quality of

Recommendation Evidence
1 Clinical signs and symptoms that warrant
admission
Recommendation 1: Among patients with Strong Low and
confirmed or presumptive diagnosis of dengue in Very low
the outpatient setting, patients with the following
signs and symptoms should be admitted in a
healthcare facility for closer monitoring and
observation:
 Shortness of breath
 Irritability or drowsiness
 Pleural effusion
 Abdominal pain
 Melena
 Elevated hematocrit
 Decreased or decreasing platelet count

Recommendation 2: Among patients with Strong Very low

confirmed or presumptive diagnosis of dengue in
the outpatient setting, there is insufficient evidence
to say that vomiting is associated with more severe
dengue. However, because patients with vomiting
cannot tolerate oral rehydration fluids, consider
admission

1 Clinical Practice Guidelines on Dengue in Children

2 Risk factors that are associated with mortality
Recommendation 1: Patients with dengue who Strong Moderate,
present with any one of the following clinical low and very
findings may be at increased risk for mortality. low
 Hypotension on admission
 Narrow pulse pressure on admission
 DHF stage 3 and 4 (severe dengue)
 History of previous dengue
 Prolonged shock
 Respiratory failure
 Liver failure (AST elevation > 200 u and INR
> 1.3)
 Renal failure (BUN >20 mg% and serum
Creatinine >1.0mg %)
 Significant bleeding including gastrointestinal
bleeding
 Severe plasma leakage in multiple sites
(pleural effusion, pericardial effusion and
ascites)

Recommendation 2: The presence of two or more Strong Very low

of the following warning signs in patients with
dengue may increase the risk for mortality:
 severe abdominal pain
 arterial hypotension
 neurologic manifestation
 painful hepatomegaly
 hypovolemic shock
 liver failure
 myocarditis

Recommendation 3: Patients with dengue who Strong Moderate,

present with one or more of the following low and very
laboratory findings may be at increased risk for low
mortality and warrant hospital admission for close
monitoring
 Decline in Hgb by > 20%
 Thrombocytopenia, with APC < 50,000/mm
3

 Hemoconcentration, with Hct > 40 % or 20%

increase in lowest and highest hematocrit
 Creatinine > 1 mg %
 AST > 1000 u
 Acidosis

Recommendation 4: Prothrombin time (PT) and Strong Low

Partial Prothrombin Time (PTT) do not differentiate
those who may be at increased risk for mortality
and are not recommended as routine tests for
patients with dengue

3 Clinical signs and/or laboratory findings that

indicate significant bleeding
Recommendation 1: Among patients admitted Strong Low to very
because of dengue, the presence of one or more low

2 Clinical Practice Guidelines on Dengue in Children

 of the following clinical or laboratory findings may
increase the risk of bleeding
• Hypotension
• Narrow pulse pressure
3
• Platelet count < 50,000/mm
3
• WBC count < 5000/mm
• Hepatomegaly
• Elevated ALT (> 3x the normal value)

Recommendation 2: Among patients admitted Strong Low to very

because of dengue, there is some evidence to low
suggest that the following signs and symptoms
may be associated with significant bleeding.
• Vomiting
• Abdominal pain
• Restlessness
• Pleural effusion or ascites
• Rash

Recommendation 3: Prothrombin Time (PT) and Strong Very low

Partial Thromboplastin Time (PTT) were not shown
to be significantly associated with bleeding and
should not be routinely done in patient with
dengue.

4 Isotonic compared to hypotonic IVFs in

reducing mortality among dengue patients
without shock
Recommendation: Strong Low
 There is insufficient evidence that the tonicity of
the intravenous fluid has an effect on mortality
in dengue patients without shock.
 Isotonic fluids can be used as maintenance for
dengue patients without shock.
 The use of hypotonic IVF is associated with
hyponatremia among hospitalized pediatric
patients.

5 Colloids compared to crystalloids in reducing

mortality among dengue patients with shock
Recommendation:
 In dengue patients with shock, either Strong Low and
crystalloids or colloids may be used for fluid very low
resuscitation.
 There is insufficient evidence to say that the
use of colloid IVF compared to crystalloids will
have an effect on mortality.
 The use of colloids may be associated with
more adverse reactions (e.g. bleeding, allergic
reactions) compared to crystalloids.

6 Prophylactic platelet transfusion in improving

platelet count, preventing hemorrhage and
reducing mortality among patients with
thrombocytopenia because of dengue

3 Clinical Practice Guidelines on Dengue in Children

 Recommendation:
 There is insufficient evidence to say Strong Moderate to
that prophylactic platelet transfusion in very low
patients with minimal or no active
bleeding will improve platelet counts,
prevent hemorrhage and reduce
mortality.
 Children with dengue who have
3
platelet count <50,000/mm with
minimal or no active bleeding should
not be given prophylactic platelet
transfusion.

7 Plasma transfusion in controlling bleeding and

reducing mortality among dengue patients with
significant bleeding
Recommendation:
 Among dengue patients with significant Strong Low
bleeding, there is insufficient evidence that
plasma transfusion has an effect on controlling
bleeding and reducing mortality.
 The effect of plasma transfusion on platelet
count recovery is not significant in dengue
patients with bleeding.
 In children exhibiting signs of disseminated
intravascular coagulopathy (DIC), plasma
transfusion may be considered.

8 Citronella-based repellents compared to DEET-

based repellents in reducing the incidence of
Dengue
Recommendation:
There is insufficient evidence to say that use of Strong Very low
citronella-based repellents is more effective than
DEET-based repellents in reducing dengue
transmission.

asping or apnea may also be features in hypotensive shock with cardiopulmonary failure.

4 Clinical Practice Guidelines on Dengue in Children